Speech by BMA GPC chair Dr Laurence Buckman at LMC Conference
Who here is worried about the future of the NHS?
Because I am.
This time last year I stood here and said that the times were exciting and worrying. Back then we were at the beginning of a new venture in democracy with a government which made much of wanting to engage with GPs. Yet we knew that, financially, times were extremely tough.
Since then the whole of the UK has had to cope with the paradox of the government telling us that there is more money coming into the NHS than ever, yet GPs can see plummeting funding and shrinking structures. And in England, a government that had promised no major organisational changes to the NHS while in opposition introduced a mere trifle - the Health and Social Care Bill. While the Celtic nations look on relieved that they are not going to have to go through it, this Bill, whether substantially amended or not, is going to alter the face of the English NHS forever. Healthcare in the UK may never be aligned again. Not only is the cost of the re-organisation staggering and wasteful but it’s not even law yet and the current structures of the NHS are already collapsing all over the place.
So a year on I’m not excited any more. I am very concerned about where all this will lead.
Because right now, as a result of the financial crisis, the NHS is not just being cut to the bone but whole limbs are being amputated. If you cut off the legs of the NHS what happens? It falls over.
And on top of this we have the Bill. The consequences of this for education and training are serious. The rapid shut-down of strategic health authorities risks wrecking the deaneries, doing great damage to training the next generation of GPs and other doctors. Instead of UK workforce controls - which we badly need - we are being offered "skills networks" in England. I want proper controls nationally considered, not locals trying to sort things out. What a way to plan NHS workforce numbers.
What saddens me is that many of you sitting in this hall, indeed many of the GPs that we represent, will have seen the proposals for GP commissioning when they were first announced as an opportunity to shape the NHS for the better - something we have not been able to do collectively for many years. Across the UK, GPs have the skills and knowledge and are willing to plan care for their patients. We genuinely believe that greater clinical involvement can make the NHS better and more efficient. But we do not want it at any price.
Because, while we see the potential benefits of clinically led commissioning, the government’s continuing attitude to competition takes an idea that could be fruitful and turns it into something rotten.
The BMA does not support the unfettered extension of private involvement into the NHS - which will not be a problem in the Celtic nations who are not going to do it. We should not blame just this government for the wide scope of privatisation contained in the bill. The previous government and several before that have all wanted to increase private provision in the NHS to various extents. And sadly, this government, just like the previous one, has a hot line to advisers from foreign management companies. These people have been circling opportunistically and have been paid a fortune of taxpayers’ money to create rivals to the NHS - with the end result that it will be harder for patients to get joined-up, efficient care. This new Bill threatens to generate a fragmented service that will benefit these private organisations, who will show the NHS no mercy. Their words not mine.
The difference between this government and others is that it has made a science out of competition by creating new, threatening and unnecessary powers for the competition regulator Monitor. This week, the Prime Minister offered a welcome change to Monitor’s role so that they will be able to encourage integration - but he still has not taken away the duty to promote competition. I want politicians of every stripe to understand that we do not need competition to run the NHS. It creates duplication that is wasteful - and why give NHS money to private shareholders? What the NHS needs to improve quality and efficiency is collaboration and co-operation across the primary, community and hospital care sectors. So a patient gets a seamless service in the settings most appropriate to them, rather than different bits of care being delivered by different providers in order to try to get a cheaper deal - a scan in one place, treatment in another, tests in another and follow-up somewhere else. This is what would make the NHS more efficient and better for patients. Some GPs and managers go further and suggest that "integration" would be desirable. Really? Surely, this depends on exactly what sort of integration it is. At the moment we have hospital managers telling consultants that they cannot talk to GPs as this is "commercial in confidence". Secondary care already sucks up the majority of NHS resources and with cuts to funding, absorption into hospitals isn’t likely to leave much behind for the bulk of the care provided in general practice. Shared working and pathways - yes, but the vista suggested by some hospital chief executives - that GPs should be employed by foundation hospitals, no.
While the NHS always needs to find ways to improve I must admit I am still struggling with why these reforms are the answer. We are all very aware that plenty of change needs to happen to ensure our NHS can cope with the ever increasing pressures it faces. But consider these facts: the most recent British Social Attitudes survey showed that more members of the public than ever believe the NHS is doing a good job; none of the Celtic countries are reforming their NHS; and the NHS has to find £20 billion in "efficiency savings" or cuts over the next four years. So why turn the NHS upside down with this legislation now?
Because that’s the thing... clinically led commissioning doesn’t need legislation. Small changes to PCT structures could have achieved what the government wants to do with far less cost and no threat to the NHS. Indeed several leading commissioning groups have been running healthcare for years with forward-thinking PCTs. Many GPs in the Celtic nations would like their health services to listen to them too as they have plenty of thoughts on how their NHS could work better for patients.
The mess the UK government is in now could all have been avoided if they had truly listened earlier on, but, as usual, the last ones to be listened to at the point of implementation are ordinary GPs. Why do governments always run to enthusiasts and advisers with a vested interest first? The previous government did it repeatedly, and now this one is listening to those who are committed to the private sector and letting them help shape this government’s policies. We too have been telling the government what we think - and we will know within a matter of days whether they have been listening to us.
So, where we are now is that there is only one way to get the NHS reforms to work with minimal private incursion into the management of the NHS or supply of services, and that is to persuade MPs and peers to start again or to make major revisions to the Bill. Progress of the Bill has so far missed opportunities to make numerous far-reaching amendments. At last, the Prime Minister is making encouraging noises, though the listening does not stop until next week when the Future Forum are due to announce their thoughts.
We await the outcome of the ‘listening exercise’ with interest. We hope they really listen to the concerns expressed in this conference hall today and by our members through repeated BMA surveys. What do we want to see? Well, we want an explicit duty on commissioning consortia to fully involve all relevant clinical staff. We want Monitor’s primary duty to be to ensure comprehensive and integrated services rather than to promote competition. And we want a more realistic timetable for the handing over of all responsibilities to all commissioning consortia. Above all we want patients to be reassured that their GP continues to place their needs at the heart of their clinical decisions.
My plea to the Future Forum and the government is please do not let this exercise just be a re-spray job to try to persuade us to accept the unacceptable. If GPs, the BMA, almost every player in the NHS, large swathes of the public and even politicians across the spectrum are ignored, then we are in for a torrid time in the English NHS.
Which brings me to one particularly unacceptable idea in the Bill: performance-related bonuses for consortia, otherwise known as the "Quality Premium". The idea is that consortia in England that "commission wel" i.e. save money will be given some money to hand out to their GPs somehow. And what do we find in the BMA survey of opinion published today? Three quarters of GPs think this idea stinks. GPs will not take money for reducing care for patients. Indeed, we will not agree to anything that gives patients the slightest perception that we might be making money out of reducing care to patients. This is utterly unethical. I have already made it clear to government that we will not even discuss such an appalling notion – now that they know the GP population is backing me I hope they will listen.
The government should be clear too, despite what they often claim, GPs joining consortia does not equate to GPs supporting the Bill. Getting into the lifeboats is not the same as supporting the sinking of the Titanic. A minority are supportive, yes, but the vast majority are taking part because they know they have no choice. They are joining in because they can see PCTs collapsing after a highly irresponsible laissez-faire approach to primary care planning. Despite the Pathfinder GPs telling us in the BMA’s MORI survey that two thirds of them think increased competition will make the quality of care worse, GPs are pragmatists and know that it is better to be involved early on, mitigate the damage and try to ensure that the new arrangements develop positively.
Which brings me to the make-up of consortia. The GPC has produced and will continue to produce guidance for GPs on commissioning consortia - I hope you find them useful. But I am very concerned that there seem to be rather too many consortia that are not involving sessional GPs properly or at all. The GPC takes the firm view that all GPs, whatever their contractual status, should be able to elect and be elected to consortia boards. No GP must ever be able to say that they were disenfranchised from any part of the electoral process. I wrote to LMCs in May to tell them that this was our view and that they should warn consortia that flout this that GPC will be observing the process to ensure that they do follow Conference policy. I have already written to the Secretary of State to advise him of the necessity of having clear constitutions and rules of engagement for consortia so that all GPs are properly involved.
Last year has also seen the first full year of the Sessional GPs Committee and they have been able to deliberate on matters that affect them, as well as contributing fully to wider GPC debates. I hope that sessional GPs now feel more comfortable with the democratic arrangements now in force. They are a large and important constituency and their presence is valued and welcome. It is essential that their voice is also heard in LMCs locally, and within emerging consortia in England.
The role of LMCs will expand over the next few years as the health landscape changes. In England, LMCs will also have to ensure that their local consortia are properly constituted, and act as the corporate memory of the NHS as the rest of the local NHS vanishes. The phrase "where does it say in the regulations..." will pass many more LMC lips before the year is out. Fighting for GPs is what LMCs do and we must ensure that every GP feels a part of the LMC, both as a member and as an elector, and that every GP knows that their LMC will stand up for them. In future, this will mean LMCs standing up for the mass of GPs in their dealings with the consortia. LMCs will rise to this task as they have always done.
GPC will be there too, issuing guidance about anything that GPs and LMC want information on, including how to deal with the CQC of which more in a minute, cope with life, and interact with the NHS.
In the Celtic nations, GPs have had to put up with many of the same problems as English GPs, but under threat of real pay cuts and, for many, no chance of having any kind of handle on the way the NHS works for them and their patients. Although some of the governments are as GP friendly as the English, if not more so, the funding and the will to let GPs improve the NHS just isn’t there. This year we had the near disaster of the Northern Irish administration deliberately stopping GMS negotiations for the whole of the UK while they tried to prevent Irish GPs from getting the same deal as the rest of us. That dreadful scenario will not happen again if we can help it. Our UK solidarity paid off as Stormont paid up. As they should have done all along.
Negotiations this year have been tougher than usual, in an impossible financial environment. Last year meant that we got rid of the dafter bits of a national survey that unfairly punished some practices, and replaced it with a local one that might actually be useful. PE7 and 8 are no more. QOF is likely to be more stable and arrangements for looking after those with depression will be more sensible. Next year will be worse. Undoubtedly, we will be pushed to agree to more "efficiencies" - which means pay cuts - and we will resist. GP expenses are rising fast and I really do not believe we can cut our staff pay without damaging morale and efficient working. Practices have nothing left to cut. GP partners are NOT like other doctors who are salaried to large organisations - any cut affects us directly and personally. We have done our bit over four years of pay freeze and do not want any more unique punishment, thank you.
PMS practices have been in the pay vice too. They entered into contracts in good faith, did what was asked of them and now they are looking at the long drop. While the government maintains the fiction that we do not negotiate for them, we will continue to try to get them the slowest downward trajectory possible.
On the torture horizon is CQC. The idea of provider registration is not new or difficult for GPs, and we recognise the potential benefit for patients, but in its current form it does require a huge amount of time and effort - when there already aren’t enough hours in the day for everything else we have to do. The model forced on CQC by legislation is complex, burdensome and will be costly for GPs. Moreover, since none of us will derive any benefit for registering, it is simply a tax on our income. If it is a tax that will ultimately depend on the taxman to pay up, why don’t CQC and DH cut out the middle man and just let Treasury give CQC the money they require to do their job? Why doesn’t the government amend the legislation to enable CQC to be less prescriptive and make our lives easier? At present, the whole thing is too complex for its own good. It will be a creative writing exercise that will cost money and take GPs away from patient care. CQC have announced a delay in GP registration, but we must get the method of funding sorted as well as the compliance process before the green light is turned on again.
What else might the government come to us with next year? Getting rid of practice boundaries perhaps? I can see on the face of it why patients might find it appealing, but I would remind those who are enthusiastic for unfettered choice that their freedom to choose restricts those who cannot exercise their choices so easily. Our society is run geographically and GPs, as primarily community doctors, inevitably relate to geographies. That does not have to limit patient choice and the GPC have proposed solutions several times in the last decade. Despite making a big thing of practice boundaries in the Health White Paper consultations last year the government have now gone very quiet on this. Is it because they realise what an impossible and expensive task they’ve set themselves? Does it surprise you that our survey of GP opinion found that eighty five percent of GPs do not think practice boundaries should be abolished? No, I thought not. Why? Because, unlike the politicians, we and all the other GPs out there know it’s a barking idea. How does continuity work if the patient can have a GP who, due to distance, cannot visit and who does not know the environment in which they live? What happens to the vulnerable, the criminal, the housebound and those who should not be allowed to change because their choices are motivated by risk taking or avoidance of surveillance? It’s a proposal which would increase bureaucracy and costs for the NHS at a time when it can least afford it. Why don’t governments listen? Deafness? Ear wax? We will continue to push the GPC alternative way forward - which is cheaper, simpler and will improve access and choice of practice for patients, including those who want to be seen away from home.
Conference, this year has been dominated by cuts to the NHS across the four countries, an NHS reform in England that has introduced clinical commissioning that has promise, yet tied it to enforced commercialisation and a draconian and ill-thought-through set of rigid rules that are unpalatable and will not work.
Next year we have to face possible terminal damage to our pensions - along with the rest of the public sector, even though the NHS pension scheme has only recently been reformed and is in surplus - so it gives money back to the Treasury. We will not forgive these attempts to damage the pensions for which we have worked and paid.
GPC have been much more involved with policy planning at the highest level than we were under the previous government, and we have been able to influence things, but there are still daft ideas dribbling out from the departments of health and we have not been able to stop all of them. We will, however, continue to try.
In a very difficult year for the NHS, GPs must ensure that the service we offer is consistently good, and that patients are as protected as much as possible from the lack of NHS funding. We will do our best whatever the political state of play. GPs are at their best when providing care for their patients - we don’t need to have our borders redefined, care patterns made more complex, patients turned into commodities or another reorganisation. Give us new tasks if they make sense and we have the time to do it, and then let us do our job - making people better.
Speech by BMA GPC chair Dr Laurence Buckman at LMC Conference